A glaring gap in the country’s strategy against covid-194 min read . Updated: 15 Sep 2020, 09:02 PM IST
India needs to contain not just the pandemic’s spread but also the high risks posed by covid co-morbidity
With a sharp surge in covid cases, rise in fatalities and a somewhat narrowly-focused strategy to fight the pandemic, the bigger picture seems to be getting overlooked. The emphasis on flattening the curve of infections and fatalities is justified, of course, but limited. India is near the 5 million infection mark, and now accounts for over 12% of active cases globally and about 8% of all covid deaths.
Deep linkages exist between the covid pandemic and non-communicable diseases (NCDs) such as diabetes, hypertension and cardio-vascular diseases. As the risk of dying from covid is significantly higher among those aged 60+ years suffering from NCDs, two issues are pertinent. A recent Lancet comment points to an underestimation of covid fatalities by excluding deaths from multi-morbidity. While the World Health Organization’s guidelines are emphatic on their inclusion, Indian states have followed their own ad hoc estimation procedures. A case in point is West Bengal, which used to exclude deaths due to multi-morbidities from covid deaths, but stopped this practice. In the absence of standardized methods across states to count covid-related deaths, deep suspicions of data reliability persist.
A second and more worrying issue is that a narrowly-focused anti-covid strategy could cause great harm to those suffering from NCDs. Not only are they denied medical attention, they also bear the brunt of hospitals going all out to accommodate covid patients. According to a Lancet editorial, covid and NCDs form a dangerous relationship, experienced as a “syndemic" that is exacerbating social and economic inequalities. A modelling exercise shows that every fifth person in the world is at increased risk of severe covid should s/he get infected, mostly on account of underlying NCDs.
NCDs account for 63% of all deaths in India and these are expected to rise further.
At an individual-level, risk factors are influenced by broader environmental, economic, infrastructural and social conditions. Addressing these risks requires multisectoral action by agencies beyond the nodal ministry/departments of health. In particular, creating an environment that facilitates greater physical activity and allows for affordable and healthy dietary choices as a complementary goal would be beneficial.
Behavioural changes matter. Lack of physical activity and an unbalanced high-calorie diet promotes weight gain. Obesity is a risk factor for cardiovascular disease and diabetes.
Although the evidence on dietary and other lifestyle changes in response to India’s draconian lockdown is patchy, it does illustrate constrained behavioural outcomes.
According to rating agency Icra, demand for sugar declined significantly following the lockdown, and the overall adverse impact on sugar consumption would be at least 1 million tonne in the domestic market, resulting in a decline in sugar prices. Excessive sugar consumption causes obesity. Sweet beverages make up a large share of all sugar intake. With the nationwide lockdown, producers of ice cream, soft drinks and confectionery items shut down their operations. Usually, the year’s first quarter is high-demand season for sugar, driven by demand for ice cream and soft drinks as the summer kicks in.
Women who drink one or more sugary beverages a day are over 20% more likely to be diagnosed with cardiovascular disease. Women with the highest sugar-sweetened beverage intake are often younger, more likely to be current smokers, obese and less likely to eat healthy foods.
Smokers are more likely to develop severe symptoms or die from covid, as it primarily attacks the lungs. Moreover, tobacco use is a major risk factor for the world’s four main NCDs—cardiovascular disease, cancer, chronic lung disease and diabetes—which puts people with these conditions at higher risk of developing severe illness if they are infected by the virus. A recent survey revealed that 68% of smokers have reduced their consumption because of higher cigarette prices and lack of availability.
Alcohol drinking is associated with cirrhosis of the liver and cardiovascular diseases. However, for most state governments, liquor revenues are a cash cow. Hence, they have followed a schizophrenic approach. On 4 May 2020, after 40-45 days of closure, liquor vends reopened in India. Pent-up demand manifested itself in the long—and almost wholly male—queues that emerged at vends, with complete abandonment of physical distancing norms. To reduce crowds, Delhi imposed a 70% “special corona fee" with immediate effect. But evidence shows that demand for liquor is highly inelastic.
Yet, another survey of young Indian adult smokers offers grounds for some optimism.
Tobacco and nicotine users in India have proven more likely than those in other countries to increase their use of healthy coping mechanisms during the covid crisis (64% said they took to physical exercise, 58% adopted breathing exercises, and 55%, yoga). Two-thirds of the 1,500 smokers surveyed expressed a desire to quit smoking for health reasons. This is especially pronounced among a vast majority of younger smokers who have tried to quit their habit during the lockdown (72% of smokers between the ages of 18 and 24, and 69% of smokers between the ages of 25 and 39).
In conclusion, while the evidence is still mixed, there is no doubt that the dangerous link between covid and NCDs needs to be weakened substantially.
Vani S. Kulkarni and Raghav Gaiha are, respectively, lecturer in sociology and research affiliate, University of Pennsylvania, USA